APPLICATION FOR PAYMENT
CONTRACTOR: FORMTEXT ?????ADDRESS: FORMTEXT ?????PHONE NO:( FORMTEXT ???) FORMTEXT ???- FORMTEXT ????FEDERAL. ID NO.: FORMTEXT ??- FORMTEXT ?????CONTRACT DATE: FORMTEXT ?????APPLICATION NO.: FORMTEXT ?????UCSD CONTRACT NO: FORMTEXT ?????APPLICATION DATE: FORMTEXT ?????PLANT ACCOUNT NO: FORMTEXT ?????PERIOD TO: FORMTEXT ?????UCSD PROJ. NO.: FORMTEXT ?????PROJECT NAME: FORMTEXT ?????*Contractor name, Federal ID No. and Address should match the most recent W-9 on file with UCSD and will be reflected on check and where payment is mailed. *Contract Date is from the Notice to Proceed. CERTIFICATE OF PAYMENTIn accordance with the Contract Documents, based upon Project site checks and the data comprising the above-referenced Application for Payment, the Owner’s Representative certifies to the Owner that, to the best knowledge, information, and belief of the Owner’s Representative, the Work has progressed as indicated in the Application For Payment, the quality of the Work is in accordance with the Contract Documents, and the Contractor is entitled to payment of the AMOUNT CERTIFIED.AMOUNT REQUESTED ON APPLICATION FOR PAYMENT FORMTEXT ?????CURRENT RETENTION % FORMTEXT ???%UNIVERSITY HELD RETENTION (5c) FORMTEXT ?????TO BE DEPOSITED INTO ESCROW (5a or 5b) FORMTEXT ?????AMOUNT CERTIFIED (balance due is auto calculated) =AmountReqAppPayment-UniversityHeldRet-ToBeDepInEscrow \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ???% PERCENTAGE OF WORK COMPLETED IN CALIFORNIA (needed for tax purposes, typically 100%)Approvals:* CONTRACTOR’S AUTHORIZED REPRESENTATIVE (if applicable): FORMTEXT ?????DATE: FORMTEXT ?????For CPM use only:UCSD PROJECT MANAGER:DATE:UCSD PROJECT INSPECTOR:DATE:UCSD FISCAL MANAGEMENT:DATE:This Certificate is not negotiable. The AMOUNT CERTIFIED is payable only to the Contractor named herein. Issuance, payment, and acceptance of payment are without prejudice to any rights of the Owner under the Contract.APPLICATION FOR PAYMENTApplication Number: REF ApplicationNo \* MERGEFORMAT Period to: REF PeriodTo \* MERGEFORMAT TO UNIVERSITY: THE REGENTS OF THE UNIVERSITY OF CALIFORNIAAND UNIVERSITY’S REPRESENTATIVE: FORMTEXT ?????FROM CONTRACTOR: REF Contractor \* MERGEFORMAT ADDRESS: REF Address \* MERGEFORMAT PROJECT NAME: REF ProjectName \* MERGEFORMAT UCSD PROJECT #: REF ProjectNumber \* MERGEFORMAT FACILITY:UNIVERSITY OF CALIFORNIA, SAN DIEGOCONTRACT DATE: REF ContractDate \* MERGEFORMAT APPLICATION DATE: REF ApplicationDate \* MERGEFORMAT CHANGE ORDER SUMMARY – If attaching additional page, list total.AdditionsDeductionsChange Orders approved in previous months.Total: FORMTEXT ????? FORMTEXT ?????Fully executed Change Orders approved this month:Number:Date Approved:AdditionsDeductions FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Current Month’s Total: FORMTEXT =Additions1 + Additions2 + Additions3 + Additions4 + Additions5 0$0.00 FORMTEXT =Deductions1 + Deductions2 + Deductions3 + Deductions4 + Deductions5 0$0.00Application is made for payment under the Contract as shown below and in Schedule 1 attached hereto:ORIGINAL CONTRACT SUM (Refer to Notice to Proceed) FORMTEXT ?????NET CHANGE BY CHANGE ORDERS FORMTEXT ?????CONTRACT SUM TO DATE (auto-calculated, Line 1 + Line 2) =B1+B2 \# "$#,##0.00;($#,##0.00)" $ 0.00TOTAL AMOUNT COMPLETED TO DATE (Column E on Schedule 1) FORMTEXT ?????RETENTION OF COMPLETED WORK TO DATE (Column H on Schedule 1) FORMTEXT ?????This Pay App Value of Securities To Be Deposited in Escrow FORMTEXT ?????This Pay App Value of Retention Deposited in Escrow FORMTEXT ?????This Pay App Value of Retention Held by University FORMTEXT ?????Current Retention Value (a + b + c) =B6+B7+B8 \# "$#,##0.00;($#,##0.00)" $ 0.00TOTAL EARNED TO DATE LESS RETENTION (auto-calculated, Line 4 less Line 5) =TotalAmCompToDate-RetWorkCompToDate \# "$#,##0.00;($#,##0.00)" $ 0.00TOTAL AMOUNT PREVIOUSLY PAID (Line 6 of previous pay app) FORMTEXT ?????CURRENT PAYMENT DUE (auto-calculated, Line 6 less Line 7) =B10-B11 \# "$#,##0.00;($#,##0.00)" $ 0.00BALANCE TO FINISH, PLUS RETENTION (auto-calculated, Line 3 less Line 6) =B3-B10 \# "$#,##0.00;($#,##0.00)" $ 0.00*Pursuant to Article 9.2.2 of the General Conditions.The undersigned Contractor hereby represents and warrants to University that all Work, for which Certificates For Payment have previously been issued and payment received from University, is free and clear of all claims, stop notices, security interests, and encumbrances in favor of Contractor, any Subcontractor, and any other persons or firms entitled to make claims by reason of having provided labor, materials, or equipment related to the Work.The following Schedules are attached and incorporated herein, and made a part of this Application For Payment:Schedule 1Cost Breakdown ScheduleSchedule 2Certification of Current Market Value of Securities in Escrow in Lieu of RetentionSchedule 3List of Subcontractors (if required)Schedule 4Declaration of Releases of Claims (if required) REF Contractor \* MERGEFORMAT (Contractor)By: FORMTEXT ?????(Name) FORMTEXT ?????(Title)Please complete entire 7-page form before e-signing the declaration below.I, REF PreparerName \* MERGEFORMAT , hereby declare that I am the REF PreparerTitle \* MERGEFORMAT of the Contractor submitting this ApplicationFor Payment; that I am duly authorized to execute and deliver this Application For Payment on behalf of Contractor; and that all information set forth in this Application For Payment and all Schedules attached hereto are true, accurate, and complete as of its date.I declare, under penalty of perjury, that the foregoing is true and correct and that this declaration was subscribed at FORMTEXT ?????, FORMTEXT ?????, State of FORMTEXT ?????on FORMTEXT ?????(Street Address)(City)(Signature – after converted to PDF) REF PreparerName \* MERGEFORMAT (Print Name) PROJECT NAME: REF ProjectName \* MERGEFORMAT APPLICATION DATE: REF ApplicationDate \* MERGEFORMAT APPLICATION NUMBER: REF ApplicationNo \* MERGEFORMAT PERIOD TO: REF PeriodTo \* MERGEFORMAT PROJECT NUMBER: REF ProjectNumber \* MERGEFORMAT CONTRACTOR: REF Contractor \* MERGEFORMAT FACILITY:UNIVERSITY OF CALIFORNIA, SAN DIEGOCONTRACT DATE: REF ContractDate \* MERGEFORMAT SCHEDULE 1TOAPPLICATION FOR PAYMENTCOST BREAKDOWNEnter the total on this page below. Attach supporting documentation to verify calculations.ABCDEFGHITEM NO.DESCRIPTION OF WORK ACTIVITY OR OTHER ITEM AND APPROVED CHANGE ORDERSSCHEDULED VALUE% COMPL.TOTAL AMOUNT COMPLETED TO DATE(C x D)TOTAL AMOUNT COMPLETED ON PRIOR APP FOR PAYMENTAMOUNT OF THIS APPLICATION(E – F auto-calculated)RETENTION(5% unless otherwise approved) FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E3-F3 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E4-F4 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E5-F5 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E6-F6 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E7-F7 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E8-F8 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E9-F9 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E10-F10 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E11-F11 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E12-F12 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E13-F13 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ????? FORMTEXT ?? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? =E14-F14 \# "$#,##0.00;($#,##0.00)" $ 0.00 FORMTEXT ?????TOTAL (auto-calculated): =SUM(ABOVE) \# "$#,##0.00;($#,##0.00)" $ 0.00 =SUM(E3:E14) \# "$#,##0.00;($#,##0.00)" $ 0.00 =SUM(ABOVE) \# "$#,##0.00;($#,##0.00)" $ 0.00 =SUM(ABOVE) \# "$#,##0.00;($#,##0.00)" $ 0.00 =SUM(H3:H14) \# "$#,##0.00;($#,##0.00)" $ 0.00PROJECT NAME: REF ProjectName \* MERGEFORMAT CONTRACTOR: REF Contractor \* MERGEFORMAT UCSD PROJECT #: REF ProjectNumber \* MERGEFORMAT APPLICATION #: REF ApplicationNo \* MERGEFORMAT SCHEDULE 2TOAPPLICATION FOR PAYMENTCERTIFICATION OF CURRENT MARKET VALUEOF SECURITIES IN ESCROW IN LIEU OF RETENTION (if applicable)As of FORMTEXT ?????,(not earlier than 5 days prior to the date of the Application For Payment of Which this certification is a part), the aggregate market value of securities on deposit in EscrowAccount No. FORMTEXT ?????with FORMTEXT ?????(Escrow Agent)Is FORMTEXT ?????Dollars ( FORMTEXT ?????). REF EscrowAgent \* MERGEFORMAT REF Contractor \* MERGEFORMAT (Escrow Agent)(Contractor)By: FORMTEXT ?????By: REF PreparerName \* MERGEFORMAT (Name)(Name) FORMTEXT ????? REF PreparerTitle \* MERGEFORMAT (Title)(Title)Date: FORMTEXT ?????Date: FORMTEXT ?????NOTE: Notary acknowledgement for Contractor and Escrow Agent must be attached.PROJECT NAME: REF ProjectName \* MERGEFORMAT CONTRACTOR: REF Contractor \* MERGEFORMAT UCSD PROJECT #: REF ProjectNumber \* MERGEFORMAT APPLICATION #: REF ApplicationNo \* MERGEFORMAT SCHEDULE 3TOAPPLICATION FOR PAYMENTLIST OF SUBCONTRACTORSSubcontractors listed below are all Subcontractors furnishing labor, services, or materials for the period referred to in the Application For Payment referenced above, of which this Schedule 3 is a part:(attach additional pages if needed)Name of SubcontractorSubcontracted Work ActivityDate Work Activity Completed FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? REF Contractor \* MERGEFORMAT (Contractor)By: REF PreparerName \* MERGEFORMAT (Name) REF PreparerTitle \* MERGEFORMAT (Title)Date: FORMTEXT ?????PROJECT NAME: REF ProjectName \* MERGEFORMAT CONTRACTOR: REF Contractor \* MERGEFORMAT UCSD PROJECT #: REF ProjectNumber \* MERGEFORMAT APPLICATION #: REF ApplicationNo \* MERGEFORMAT SCHEDULE 4TOAPPLICATION FOR PAYMENTDECLARATION OF RELEASE OF CLAIMSContractor hereby certifies that attached hereto are releases and waivers of claims and stop notices from all Subcontractorsfurnishing labor, services, or materials covered by the Certificate For Payment dated FORMTEXT ?????, except those listed below: FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? REF Contractor \* MERGEFORMAT (Contractor)By: REF PreparerName \* MERGEFORMAT (Name) REF PreparerTitle \* MERGEFORMAT (Title)Date: FORMTEXT ????? ................
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